Surge in liver transplants for alcoholic cirrhosis in Korea sparks ethical debate

The number of liver transplants for alcoholic cirrhosis has increased in Korea recently, leading to calls for working out countermeasures.

Patients with alcoholic cirrhosis are at a high risk of recurrence of liver disease due to re-drinking after transplantation, resulting in ethical issues on the equity and utility of organ allocation and an urgent need to find a solution.

The Korean Liver Transplantation Society emphasized the changing trend of liver transplantation in Korea and the importance of post-transplantation management for alcoholic cirrhosis at a news conference on Thursday to commemorate its Fall Meeting (LT Updates 2024).

Dr. Yang Kwang-ho, head of the society’s Balanced Development Committee and a professor of the Department of Surgery at Pusan National University Yangsan Hospital, explained the changes in the underlying diseases of liver transplant patients in Korea, pointing out the continuous increase in alcoholic cirrhosis.

“The disease groups that lead to liver transplantation in Korea have shown distinct changes over the past decade,” Dr. Yang said. ”If we look at the annual number of liver transplants by disease, we can see a gradual increase in liver cancer, and one of the changes that should be noted is the phenomenon that alcoholic cirrhosis is constantly increasing.”

According to Yang, there has been a distinct upward trend in living-donor liver transplants and brain-dead liver transplants due to alcoholic cirrhosis.

In living-donor liver transplants, liver cancer accounts for more than half of the total. However, while cirrhosis caused by hepatitis B has gradually declined, alcoholic cirrhosis has steadily increased. In 2022, the number of living-donor liver transplants for alcoholic cirrhosis surpassed hepatitis B as the second leading cause of death.

Notably, alcoholic cirrhosis is the most common cause of brain-dead liver transplantation.

“The revised urgency selection method for brain-dead liver transplantation in the 2016 Model for End-stage Liver Disease (MELD) system has accelerated this trend, as patients with severe alcoholic cirrhosis can achieve very high urgency scores,” Yang said.

Since 2019, alcoholic cirrhosis has become the most common indication for liver transplantation, living or deceased, accounting for about 40 percent of deceased liver transplants and 20 percent of the total liver transplants.

The increase in liver transplantation for alcoholic cirrhosis is raising new social and ethical issues, he added.

The second speaker, Dr. Son Sun-young, chief coordinator at the Center for Organ Transplantation in Gangnam Severance Hospital, agreed.

“According to statistics from the National Institute of Organ, Tissue and Blood Management, the number of liver transplants for alcoholic cirrhosis has quadrupled over the past 15 years,” Son said. “However, in the case of liver transplantation for alcoholic cirrhosis, the resumption rate of drinking after liver transplantation is reported to be as high as 50 percent. The relapse of liver disease due to resumed drinking continues to raise ethical concerns regarding the fairness and utility of organ allocation.”

Dr. Son emphasized that for successful liver transplantation, it is necessary to confirm the ability to maintain sobriety and plan for relapse prevention when selecting transplant recipients. It is essential to have a multidisciplinary approach for ongoing relapse monitoring and socio-psychological support after transplantation.

In 2023, the society surveyed the perioperative management protocols for liver transplantation patients with alcoholic cirrhosis in Korea, finding that there is no standardized protocol in Korea varying from center to center, so the society concluded it is urgent to develop an appropriate protocol.

“At this society’s first half-year seminar on June 15, the case of 'My Liver Guardian,' a program to prevent the resumption of drinking by liver transplant patients, was presented, and the need for collaboration between transplant centers and the Integrated Addiction Management Support Center to prevent and manage relapse to drinking after liver transplantation was confirmed,” Son explained.

Son noted that on July 3, the society held a joint meeting with the Korean Association of Addiction Management Centers and the Korean Society of Addiction Psychiatry to develop a professional multidisciplinary approach for relapse prevention and management of alcoholic liver transplant patients. After discussing collaborative tasks, a multidisciplinary team of transplant surgeons, psychiatrists, organ transplant coordinators, and social workers was formed.

“We will form a multidisciplinary interdisciplinary team composed of transplant surgeons, psychiatrists, organ transplant coordinators, and social workers to develop a protocol for the management of drinking relapse in liver transplant patients with alcoholic liver disease,” Dr. Son said. “The society will continue to serve as a center for education and research to prevent drinking relapse in Korean alcoholic liver transplant patients. Through the multidisciplinary project and subsequent research, we will achieve Korean standardization, provide evidence, and ultimately induce policy change.”